Effect of ketamine versus alfentanil following midazolam in preventing emergence agitation in children after sevoflurane anaesthesia: a prospective randomized clinical trial.

OBJECTIVE: To investigate the effect of intranasal ketamine versus alfentanil in addition to oral midazolam for the prevention of emergence agitation in children. METHODS: Children undergoing urological surgery with sevoflurane anaesthesia received oral midazolam 40 min before induction and were then randomly assigned to receive 2 mg/kg ketamine, 10 µg/kg alfentanil or 1 ml isotonic saline intranasally. Parental separation status and mask acceptance were assessed preoperatively. Emergence agitation was evaluated using a paediatric anaesthesia emergence delirium (PAED) score. RESULTS: Data from 78 children were evaluated in the study. There were no significant differences between the groups in demographic characteristics, recovery times or parental separation scores. Mask acceptance was significantly better in the ketamine group than in the saline group. The mean PAED score in the ketamine group was significantly better than in the other two groups, but was similar in the saline and alfentanil groups. The incidence of emergence agitation was 3.8%, 36.0% and 40.7% in the ketamine, alfentanil and saline groups, respectively. CONCLUSIONS: The addition of intranasal ketamine to oral midazolam significantly improved the quality of induction and reduced sevoflurane-induced emergence agitation, in children undergoing urological surgery.

A comparison of two different doses of bupivacaine in caudal anesthesia for neonatal circumcision. A randomized clinical trial.

BACKGROUND: We aimed to compare the analgesia quality of caudal block of low volume, high concentration bupivacaine to the conventionally used volumes and concentrations of the drug in neonates undergoing circumcision with sole caudal anesthesia. METHODS: Fifty neonates, undergoing circumcision were randomly assigned to low volume high concentration (group LVHC, n=25) and control groups (group C, n=25). Both groups received a caudal injection: Group LVHC 0.5 ml/kg bupivacaine 0.375% (1.875 mg/kg) and group C 1 ml/ kg bupivacaine 0.25% (2.5 mg/kg). Hemodynamic parameters, block onsets and analgesia periods were compared among the groups. Pain scores were evaluated hourly for 3 hours postoperatively with NIPS (neonatal infant pain score). Statistical analyses were performed with Student's t-test for continuous variables. X(2) and Mann-Whitney U-tests were used for nominal and/or categorical variables. RESULTS: Demographic, hemodynamic data, block onset time (group LVHC and C values were 4.9 +/- 1 vs 5.2 +/- 2 mins, respectively; p=0.53) was similar and postoperative median NIPS (a median value of 0 at postoperative 1, 2, and 3. hours) were identical among the groups (p=0.7, p=0.9, p=1). None of the neonates required additional analgesic for the first 24 hours following the surgery; therefore postoperative analgesic requirement was similar among the groups (p>0.1). CONCLUSIONS: Low volume high concentration caudal bupivacaine provided a similar perioperative analgesia quality, time and safety profile compared to conventional bupivacaine doses in awake neonates undergoing circumcision. Low volume, high concentration bupivacaine may be used to reduce the risk of local anesthetic toxicity in outpatient neonates.

Effects of hydroxyzine-midazolam premedication on sevoflurane-induced paediatric emergence agitation: a prospective randomised clinical trial.

BACKGROUND AND AIM: Anaesthesia with sevoflurane leads to a high prevalence of emergence agitation in paediatric patients. This study investigates the effects of combining hydroxyzine and midazolam on sevoflurane-induced emergence agitation in paediatric patients undergoing infraumbilical surgery with a caudal block. PATIENTS AND METHODS: Eighty-four children 1-7 years of age undergoing general anaesthesia with sevoflurane and caudal block were assigned to two groups. Children in group M (n = 42) were premedicated with 0.5 mg kg oral midazolam and children in group MH (n = 42) were premedicated with 0.5 mg kg oral midazolam and 1 mg kg hydroxyzine given 30 min before anaesthesia induction. A caudal epidural block was performed following anaesthesia induction. Induction quality, parental separation scores and emergence agitation were evaluated. Emergence agitation was evaluated with the PAED score (Paediatric Anesthesia Emergence Delirium) every 5 min during the first 30 min after admission to recovery room. Induction quality and parental separation were assessed with 4-point scores. Postoperative pain was evaluated with the 10-point Children's and Infants' Postoperative Pain Scale. RESULTS: Median parental separation (3 vs. 2; P = 0.01), induction quality (2 vs. 2; P = 0.03) and sedation scores (3 vs. 2; P = 0.003) were significantly better in the MH group compared to the M group. Median PAED score of group M (15) was higher than that of group MH (11; P < 0.001) and the number of children with PAED scores more than 16 was also higher in group M (n = 16) compared to group MH (n = 2; P < 0.001). None of the children had a pain score more than 3 throughout the study period. CONCLUSION: The incidence of sevoflurane-induced emergence agitation was significantly lower in children premedicated with a midazolam and hydroxyzine combination compared to those premedicated with midazolam only. Furthermore, the midazolam and hydroxyzine combination provided better premedication quality than midazolam alone.

Comparison of the effect of sevoflurane and halothane anesthesia on the fall in heart rate as a predictor of successful single shot caudal epidural in children.

OBJECTIVE: To investigate the effect of sevoflurane anesthesia on heart rate HR fall with the injection of the initial drug in caudal space to confirm the correct needle placement. METHODS: After the ethical approval was obtained from the hospital's ethics committee, a prospective, randomized, clinical study was designed in Yeditepe University Hospital, in 2007. Children aged 1-12 years, scheduled for infraumbilical surgery under general anesthesia, and caudal block were included in the study. Anesthesia was induced, and maintained by sevoflurane in group S (n=85), and by halothane in group H (n=82). Baseline HR was recorded before the caudal block was performed. The HR changes during the initial dose, and total drug injection were recorded followed by 2 more HR recordings taken 5, and 10 minutes after caudal injection. The success of the block was recorded by a blind observer. RESULTS: There were 167 children included in the study. Caudal block success was 96.5% in group S, and 97.6% in group H. Basal HR was 110.9 +/- 10.9 in group S, and 105.9 +/- 10.1 in group H. Following the initial drug injection, mean HR was 109.8 +/- 10.9 in group S, and 102.9 +/- 9.9 in group H. It was significantly lower than the baseline in group H. The only significant decrease in the HR of the patients in group S was at the tenth minute following caudal injection. CONCLUSION: The decrease in HR with drug injection has no value to predict the success of caudal block under sevoflurane anesthesia.

An old technique for surgery of 'high' undescended testis revisited.

INTRODUCTION: Most undescended testes resolve spontaneously in the first year of life. If the testis remains undescended by the second year, the most probable means of scrotal placement is orchiopexy. After the first successful operation for orchiopexy, many surgical modifications were described. This study presents our limited experience with Prentiss' maneuver in six boys with high undescended testes. PATIENTS AND METHODS: Two left, two right and two bilateral testes, in six patients, were operated. Five patients were admitted with the complaint of unilaterally or bilaterally 'empty scrotum'. The sixth patient previously had a right high undescended testis which had been placed in a high scrotal position. Following the standard steps of inguinal orchiopexy Prentiss' maneuver were performed and yielded adequate distance to place the testes mid scrotum. RESULTS: On follow-up, Doppler ultrasound examination revealed normal sized testes with normal blood flow in all patients with dimensions correlated with age. CONCLUSION: Although perhaps only useful in orchiopexy for high undescended testis, incision of the transversalis fascia preserves testicular blood flow by relieving tension on the testicular vessels.

Internal jugular vein diameter in pediatric patients: are the J-shaped guidewire diameters bigger than internal jugular vein? An evaluation with ultrasound.

AIM: This study investigates whether the diameters of right internal jugular vein (RIJV) are suitable for the use of 'big radius curved J-tip' Seldinger wires in pediatric patients. METHODS: One-hundred and thirty-five children, 1 month to 15 years of age, scheduled for pediatric surgery were divided into four subgroups according to their age (0-12 months, 1-2 years, 2-6 years old, and >6 years). Patients in the 0-12 months group were further divided into two groups as 0-6 months and 7-12 months of age to evaluate RIJV characteristics in detail. Following anesthesia induction, depth, diameter, and area of RIJV were measured with ultrasound at the level of cricoid cartilage and sterno-clavicular junction in supine and Trendelenburg position. RESULTS: Infants in the 0-6 months of age group had the least mean diameter of RIJV at both the cricoid cartilage and the sternoclavicular junction level (0.484 +/- 0.132 and 0.499 +/- 0.136 cm). The aforementioned diameter was significantly lower than the values of other age groups (P < 0.05). Trendelenburg position did not increase RIJV diameter in children below 6 and cross-sectional area below 2 years old. Correlations between age, height, weight, head circumference and RIJV diameter, cross-sectional area, depth from the skin were weak. CONCLUSION: The diameter of the IJV in pediatric patients, especially infants, is often smaller than the diameter of the J-tip guidewire curve. We speculate that this may lead to impeded guidewires and failed cannulation. It must also be kept in mind that the Trendelenberg position might not facilitate IJV cannulation in children <2 years of age.

Preoperative sonography of nonreducible inguinal masses in girls.

PURPOSE: Inguinal hernia is one of the most common surgical pathologies in childhood. Any of the abdominal organs can slide into the hernial sac and become incarcerated there. In girls, the fallopian tubes, ovaries, uterus, and-rarely-ovarian cysts can form the sliding component of an inguinal hernia. The aim of this study was to investigate the diagnostic value of preoperative sonographic examination in girls with nonreducible inguinal masses. METHODS: Nine girls ranging in age from 2 months to 8 years who were admitted to our clinic with nonreducible inguinal masses were included in the study. All patients underwent sonographic examination followed by surgery on the day of admission. RESULTS: A definitive diagnosis was obtained in 6 patients on preoperative sonographic evaluation, whereas 3 patients were misdiagnosed. One patient was diagnosed sonographically as having lymphadenopathy, but surgery revealed an ovarian cyst sliding into the hernial sac. A second patient was found to have an infected lymph node at surgery instead of a strangulated bowel loop as diagnosed on sonographic examination. In the third patient, the preoperative sonographic diagnosis was an ovarian cyst in the hernia sac, but surgery revealed a cyst of the canal of Nuck. CONCLUSION: Inguinal masses in young girls must be carefully evaluated, because the sonographic preoperative diagnosis may be misleading.

A continuous debate on contralateral processus vaginalis: evaluation technique and approach to patency.

We present our experience with the transinguinal diagnostic laparoscopy and discuss its efficacy in evaluating the contralateral side in unilateral inguinal hernias. The possible influence of the initial side of hernia, age and gender on recognized bilateralism were also evaluated in two study groups (diagnostic laparoscopy vs clinical diagnosis). In this retrospective study, we evaluated 36 bilateral, 158 left-sided and 303 right-sided consecutive inguinal hernia cases. A total of 211 out of 461 unilateral cases underwent hernia repair and transinguinal laparoscopic evaluation of the contralateral side. Complications and difficulties of the technique, the mean duration of laparoscopy and operative times were additionally analyzed from operation charts. In this study, bilateralism was determined by transinguinal laparoscopy in Group 1 (children with a contralateral patent processus vaginalis) and clinically in Group 2 those who had a metachronous hernia. The patients were also analyzed according to the side of the inguinal hernia, age and gender in both groups. We found an overall positive contralateral patency in 41 cases (19.4%). We failed to perform a successful diagnostic laparoscopy in six cases (2.7%). No anesthetic or surgical complications were noted. Transinguinal laparoscopy did not add any considerable time to the mean operation time. The incidence of bilateralism in Group 1 was higher in girls than boys. Clinically detected bilateralism was significantly higher in 0-6 month age group and contralateral patency detected via laparoscopy was high in all other age groups. We may conclude that transinguinal diagnostic laparoscopy is a feasible technique in children. We advocate its use as a tool with minimal complication risk even in the hands of novice.

Advantages of video-assisted approach in detecting epididymal anomalies and treatment of nonpalpable testis.

In children with a nonpalpable abdominal testis, preoperative localization is very helpful prior to surgical investigation both to reduce the time required and to plan the correct surgical procedure. It is no doubt that laparoscopy is useful in both diagnosis and management of nonpalpable testis. In this study, 15 patients with 17 nonpalpable testes admitted to our clinic in 2 years period were evaluated retrospectively. Ultrasound study was performed in all patients after detailed physical examination. Testicular location, size, and configuration of epididymis were determined by laparoscopy and compared with ultrasound findings. Laparoscopy, in conjunction with ultrasound, permits not only a better localization and anatomy of the testis but is also superior in planning the best choice of management. We believe that the video-assisted inguinal approach is a feasible method in the treatment of nonpalpable testis when compared to pure open surgery.

Traumatic diaphragmatic rupture in children.

BACKGROUND: We aimed to emphasize the importance of early diagnosis and treatment of traumatic diaphragmatic (TDR) rupture which is an uncommon but potentially life-threatening problem with a high incidence of associated injuries. METHODS: We presented 8 children with traumatic diaphragmatic ruptures who were admitted to our department within a 13 year period after the incident. Relevant information about clinical and radiological findings herniated organs into the thorax, type of injury and applied surgical intervention and outcome of patients were evaluated so as to draw important clues leading to early diagnosis and treatment of this potentially life threatening condition with associated morbidities. RESULTS: In five patients, TDR occurred after a blunt trauma. Five patients underwent laparotomy while 3 of them were managed with thoracotomy. The surgical interventions were performed successfully and only one patient failed to survive. One patient died of associated severe head injury. CONCLUSIONS: The TDR in children could be promptly identified and easily diagnosed, only if this pathology is highly suspected. Since, TDR must be ruled out in all severe cases of trauma, information related to the experiences of various centers must be considered as important clues which might lead to earlier diagnosis and prompt treatment.

Fibrinolytic treatment of complicated pediatric thoracic empyemas with intrapleural streptokinase.

OBJECTIVE: Proper antibiotic treatment and adequate pleural drainage is essential in successful management of pleural effusions. In complicated effusions the increased production of fibrin results in formation of loculations and septations within the thoracic cavity, leading ineffective chest tube drainage. Intrapleural fibrinolytic agents are employed to avoid thoracotomy in such complicated pleural effusions. Our study reviews the results of streptokinase treatment in children with pleural effusion. METHODS: Thirty-two patients with parapneumonic pleural effusions were admitted to our hospital. The patients beyond the exudative stage were divided into two groups according to the initial radiological findings and biochemical parameters of pleural fluid. Intrapleural streptokinase treatment was started in an average of 2 days following initial chest tube placement in both Group I (14 patients) in fibrino-purulent phase with pleural effusion and fluid volume estimated to be larger than one-third of the involved lung and Group II (18 patients) with additional findings in radiological examination regarding the presence of air-fluid levels, multiple loculations, necrotic debris and pleural thickening. The effectiveness of therapy was assessed by monitoring the volume of the fluid, the level of LDH, glucose, pH and by radiological imaging, pre- and post-instillation. RESULTS: There was statistically significant difference between two groups according to date of admission (6.8 vs 10.4 days), mean of total pleural fluid drainage before (106.9 vs 309.7 ml) and after (258.9 vs 511.2 ml) SK treatment, mean of total number of instillations (2.1 vs 3.6) required and total length of hospital stay (16.6 vs 22.4 days). There was a significant difference regarding pleural chemical analysis. Finally, surgical intervention was necessary in six intractable cases, all of which initially presented a significant small amount of pleural drainage in volume when compared to rest of the patients. The overall success rate of our treatment was calculated as 96% for G-I and 72.2% for G-II cases. CONCLUSIONS: Intrapleural streptokinase is an effective and safe adjunct in facilitating drainage in early and late stage II empyemas. A tendency of decreased rate of drainage besides persisting fever and respiratory symptoms, despite fibrinolytic treatment may be a clue for early surgical intervention.

A child with undifferentiated sarcoma of the liver complicated with bronchobiliary fistula and detected by hepatobiliary scintigraphy.

Undifferentiated (embryonal) sarcoma of the liver (USL) is a rare malignant mesenchymal tumor principally affecting patients of pediatric age. Bronchobiliary fistula is a very rare complication in patients with liver tumor. To the authors' knowledge, this is the first report of a bronchobiliary fistula resulting from tumor invasion in a child with liver sarcoma. A 12-year-old boy was diagnosed to have USL of the right liver lobe, invading the diaphragm. An extended right hepatectomy and total resection of the mass was performed, leaving patchy tumoral invasion of the anterior diaphragmatic surface followed by combined chemotherapy regimen. Six months after the operation, the presence of bilious sputum suggested a bronchobiliary fistula, which was confirmed by hepatobiliary scintigraphy. The patient underwent a right thoracotomy and fistula division. Although bronchobiliary fistula is a very rare complication in patients with hepatic tumors, suspicion in the appropriate clinical setting is necessary to recognize this problem. Hepatobiliary scintigraphy is the useful diagnostic procedure to define bronchobiliary fistula in children with liver tumor and clinical suspicion of bronchobiliary fistula.

A new algorithm for primary hypospadias repair based on tip urethroplasty.

BACKGROUND/PURPOSE: Decision making in hypospadias repair potentially can be simplified by tubularized incised plate (TIP) urethroplasty. The authors report management and outcomes in a consecutive series of primary hypospadias repairs in which the intent was to perform TIP. METHODS: Records of 106 consecutive boys undergoing hypospadias repair by 1 surgeon were reviewed. Position of the meatus, degree and management of curvature, technical details of the urethroplasty, and postoperative complications were recorded. RESULTS: Curvature was noted in 24 (23%) of patients, but could be corrected with preservation of the urethral plate in all but 3. In another boy, the incised plate was thought "unhealthy" for tubularization. The remaining 102 underwent TIP, of whom, 75 had distal and 27 had proximal hypospadias. Complications, primarily fistulas, occurred in 14 (13%) of these patients. The other 4 boys underwent staged repairs that utilized TIP for the glanular urethra at the second operation. CONCLUSIONS: The authors found decision making was no longer determined by meatal location as in the past, but by severity of curvature and appearance of the incised urethral plate. Because severe curvature requiring plate transection or an "unhealthy" incised plate are uncommonly encountered, TIP repair can be performed for most hypospadias operations.

Ultrasonographic findings after laparoscopic repair of paediatric female inguinal hernias: the 'vanishing rosebud'.

BACKGROUND: Laparoscopic surgery is a good alternative to the open technique for treating hernias in female paediatric patients. The laparoscopically inverted and sutured hernia sac forms a nodule, the long-term fate of which has not been previously studied radiologically. OBJECTIVE: To describe the early and delayed US changes after laparoscopic inversion and suturing of paediatric female inguinal hernias. MATERIALS AND METHODS: Twenty girls (age 1.5 months to 12 years; median 4.6 years) who underwent laparoscopic inguinal hernia repair were prospectively evaluated with US the day before and the day after the procedure. Delayed scans were obtained at 1, 6 and 12 months. RESULTS: The laparoscopic procedure involved inversion and suturing of the hernia sac, which resulted in a nodule that plugged the internal inguinal ring and resembled a rosebud laparoscopically. US detected the 'rosebud' in all cases on the first postoperative day. Initially appearing as a rounded or ovoid mass with a slightly hypoechoic texture, the 'rosebud' became progressively smaller, more hypoechoic and more lobulated on follow-up. It disappeared in all but two cases at 6 months and in all cases at 1 year. There was no US evidence of recurrence. CONCLUSIONS: The 'rosebud' formed by this laparoscopic procedure displays typical US features and temporal changes.

Prenatal diagnosis of a prolapsed ureterocele with magnetic resonance imaging.

Ectopic ureterocele with ureteral duplication is the most common type of ureterocele found in children. Early accurate diagnosis is desirable to decrease the risk of urosepsis and renal damage. Prenatal imaging with ultrasonography detects the vast majority of ureteroceles; however, in some cases, the diagnosis may remain in doubt. We report on the use of magnetic resonance imaging to clarify the prenatal diagnosis of a prolapsed ureterocele.